Eric P. Melzig, MD Richmond Surgical Henrico Doctors' Hospital |
One of the scariest moments for a woman is when she feels
a lump in her breast, with the human nature of fearing the worst taking over. Thoughts
of a cancer diagnosis become the immediate concern; anxiety then enters the
picture, along with the perception of a negative outcome. The good news is the
vast majority of breast lumps are benign and harmless. A similar scenario plays
out when a woman is informed that her mammogram is abnormal and further imaging
is indicated, with the vast majority of mammogram abnormalities being benign.
The evaluation of a new breast lump should begin with a
visit to one's primary care physician or gynecologist. Your physician will
perform a dedicated history and physical examination with emphasis on factors
influencing breast health. Key features of the history include the presence or
absence of nipple discharge, pain, or lymph node swelling. Is there redness of
the breast associated with the lump? This may indicate mastitis. If one is
premenopausal, has the breast lump changed in size and texture over time, and
does this correlate to the timing of the menstrual cycle? If nipple discharge
is present, is it clear or bloody, and is it spontaneous? Much information can
be gleaned from a detailed history, which can be segmented into the below
parts:
Risk
Assessment
A detailed personal risk assessment will not necessarily
dictate treatment of the newly discovered lump but can add perspective. Risk
analysis is helpful in planning a long-term approach to breast health and a
screening strategy. The salient risk factors, in order of importance, are: 1) personal history of familial genetic
mutations (Angelina Jolie's BRCA1 and BRCA2 mutation, for example); 2) personal
history of previous breast cancer; 3) personal history of non-malignant
proliferative benign disorders (sclerosing adenosis, ductal hyperplasia or
atypical ductal hyperplasia, for example); 4) breast density on mammography; 5)
family history of breast cancer; and 6) previous radiation therapy to the chest
(for example, Hodgkin's disease treatment). The risk factor generating the
greatest misconception is a positive family history of breast cancer, with
women automatically suspecting doom when they feel a breast lump. Conversely,
women with negative family history tend to feel bullet proof. Both concepts are
incorrect, as the status of the family history is an important factor, but
breast cancer is multifactorial and family history is only one of many risk
components. Ultimately, most breast cancer patients have a negative family
history of breast disease and the majority of patients with breast cancer (60%)
have no identifiable risk factors.
Physical
Examination
The breast exam alone can lead to a benign diagnosis
without imaging or biopsies. Findings such as mastitis, fibrocystic changes
with associated breast thickening, waxing and waning masses associated with
one's menstrual cycle, and lesions that are actually in the skin and not in the
breast can all be readily diagnosed as benign entities. If the palpable lesion
is indeed a true mass on physical exam, then breast ultrasound is the preferred
method of evaluation. Ultrasound will distinguish a benign simple cyst from
complex cysts and solid lesions. This distinction can lead to an
ultrasound-guided cyst aspiration and resolution of this benign lump or it can
point to the need for further investigation with additional imaging.
Diagnostic
Mammogram
After intake of a patient’s history and a physical exam,
a diagnostic mammogram is the next tool for patients aged 35 and older. If less
than 35 years of age, the accuracy of a diagnostic mammogram significantly
decreases due to the natural breast density of a young woman, as breast density
naturally decreases with age. For those under 35, a solid lesion can best be
diagnosed with an ultrasound-guided needle biopsy. At this young age, the high
percentage diagnosis is a benign fibro-adenoma.
For those over 35, the diagnostic mammogram will yield
important information concerning the nature of the mass. Is it smooth or are
the borders irregular? Does it create architectural distortion? Are there any
other lesions present that are too small to be palpated? The recent
introduction of 3D tomosynthesis with mammography adds detection sensitivity. Needle
biopsy using mammogram imaging is called a stereotactic biopsy. Imaging with
breast MRI is very sensitive in detecting breast abnormalities and is
especially helpful in patients with dense breasts. If a lesion is not
visualized on mammography, 3D tomosynthesis or ultrasound, then a needle biopsy
using MRI image guidance is the preferred diagnostic option.
Multiple well-controlled, large, randomized studies
document that annual screening mammography saves lives. As a cancer is
evolving, mammography leads to early detection. If the malignant process is
diagnosed earlier in its natural history, we are lead to higher cure rates and
less severe treatments. Despite some controversy, mammography lowers the risk of
dying from breast cancer and should be a mandatory component of every woman's
healthcare plan.
It is important to note that men are not exempt from
breast cancer. While women account for 99% of breast cancer diagnoses, men are
still at risk and 2,000 men per year in the United States are diagnosed. Therefore,
men must fight their usual reluctance to seek medical attention and have any
breast lumps examined by their physicians.
Do not panic if you find a breast lump on self-exam. Benign
diagnoses far surpass malignant diagnoses. Remain calm and consult with your
treating physicians. Personal history, physical examination, imaging, and, if
required, image-guided needle biopsy will most likely lead to a benign
diagnosis, ruling out malignancy.
For further inquiries about
breast cancer management and advancements, or HCA Virginia’s Breast CareNetwork, contact Eric P. Melzig, MD, of Richmond Surgical, at 804.285.9416, or
visit their website at richmondsurg.com.
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